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MARET 2012

1. Ny. Maah, ♀, 70 tahun, MR : 10618, Jamkesmas


MRS : 18-3-12 13.03 WIB
INA-DRG: 061402 ALOS : 12,0
DPJP : dr. Andriana P. SpB-KBD

KU : Nyeri seluruh perut


AK :
Sejak 3 hari SMRS pasien mengeluhkan nyeri di seluruh
perut yang dirasakan terus menerus dan bertambah berat.
Awalnya nyeri dirasakan di ulu hati sejak ± 1 minggu SMRS
kemudian menyebar ke seluruh perut. Demam (+), Riwayat sering
mengkonsumsi jamu – jamuan untuk pegal linu (+) sejak 1,5
tahun SMRS. Riwayat BAB mencret (-), darah (-). Riwayat BAB
seperti kotoran kambing (-). BAK tidak ada kelainan. Karena
keluhannya pasien dibawa ke RS Muhammadiyah dilakukan foto
rontgen dan cek darah, karena masalah biaya kemudian dirujuk
ke RSHS.
Pemeriksaan Fisik
Status Generalis :
KU : CM
T : 110/70 mmHg N : 112 x/m
R : 24 x/m S : 37,8oC

Status lokalis :
Abdomen: cembung, tegang, BU (-), NT (+), NL (+), DM (+)
RT : Sfingter lemah, mukosa licin, ampulla tidak kolaps, NT (+)
seluruh lingkaran, massa (-)
ST : feses (+), darah (-)
Tekanan intravesica : 15 cm H20
Foto Abdomen 3 posisi
free air (+) subdiafragma kanan
Laboratorium
PT : 17,3
• Hb : 7,8 INR : 1,47
• Ht : 24 aPTT : 24
• L : 8.300 Albumin : 2,7
• Tr : 318.000 Protein total : 4,8
• Ur : 139
Laktat : 2,4
• Kr : 2,37
• GDS : 77
AGD
• Na : 137 • pH : 7,40
• K : 3,8 • pCO2 : 25,0
• SGOT : 34 • pO2 : 65,8
• SGPT : 11 • HCO3 : 17,8
• Amilase : 234 • TCO2 : 18,5
• Lipase : 104 • BE : -6,3
• Sat O2 : 94,0
DK/ Peritonitis diffus e.c susp perforasi ulkus peptikum + sepsis
berat

Th/
Antibiotik (99.21)
Analgetik (93.5)
EGDT
Laparotomi eksplorasi (54.11)
Jam

13.00
TD

110/70
N

104
R

24
Resume
S

37.8
UO

-
Keterangan
IVFD, NGT & kateter,Cek Lab lengkap, tekanan
intravesica = 15 cm H2O
Lab : Hb/Ht/Leu/Tro : 7,8/24/8.300/318.000
Ur/Kr : 139/2,37, GDS : 77, Na /K : 137/3,8
SGOT/SGPT : 34/11, Amilase/Lipase : 234/104
PT/INR/aPTT : 17,3/1,47/24, Albumin : 2,7
14.00 100/70 104 24 37,8 25
Protein total : 4,8, Laktat : 2,4
AGD (pH/PCO2/PO2/HCO3/TCO2/BE/SatO2)
7,40/25,0/65,8/17,8/18,5/-6,3/94,0
Abdomen 3 posisi: free air (+)
15.00 120/80 100 24 30 Dilakukan pemasangan CVP: 5 cmH2O
EGDT
16.00 120/70 100 24 35

17.00 110/70 96 20 50

18.00 110/80 98 24 50

19.00 110/70 95 24 37.8 60 CVP: 9

Pasien naik OK
CVP: 8 cmH2O
AGD (Mixed Vein)
20.00 110/80 90 24 37,8 60 (pH/PCO2/PO2/HCO3/TCO2/BE/SatO2)
7,371/32,7/34,5/19,1/20,0/-6,3/73,5
Laktat  1,4
Ur/Kr : 137/2,09, Amilase/Lipase : 180/82,1
Foto Intra Op
DO (Tgl 18/03/12, pkl 22.55)
(Operator :dr. Z. Arief SpB, dr. Invicton, dr. Ridla, dr. Fikri)
Ditemukan :
• Pneumoperitoneum (+)
• Cairan peritoneum bercampur gastric juice ± 750 cc
• Perforasi gaster prepyloric dengan diameter ± 2 cm, tepi nekrotik
• Fibrin - fibrin yang masih mudah dilepaskan di subhepatik,
subdiafragma kiri, interloop usus, dan subpelvis
• Organ solid dan hollow viscus lain intak

DK Post Op/
Peritonitis difus (K.65) e.c. perforasi gaster (K25.1) + sepsis berat(T85.7)
yang telah dilakukan Laparotomi Eksplorasi (54.11) + biopsi (45.27) +
omental plug (54.74)

INA-DRG:161402 IP Other Digestive System Procedures w/CC


ALOS: 12,0
2. Mrs. Tarminah,♀, 60 yo, MR :11874 Self Payment
Admission : 27/03/2012, at 18.56,Consultant: dr.Nurhayat Sp.B(K)BD
INA-DRG : 061302 ALOS : 23,7 days

CC : Pain at whole abdomen


HT :
Five days prior to admission, patient had been
complaining of pain at whole abdomen. The pain was
initially felt at epigastric region, then suddenly spread to
the whole abdomen. The pain was felt continously and
became worse, accompanied by nausea (+), vomiting (+),
fever (-), bloating (+). Defecation (-). History of intermittent
epigastric pain (+) since 2 years ago. History of consuming
traditional medicine for rheumatic disease (+) for 3 years.
She was brought to Hasan Sadikin Hospital.
Physical examination
General Status :
 General condition : Alert
 Vital sign BP : 130/90 mmHg PR : 112x/mnt,
RR : 28x/mnt T : 36,8 0C
Local Status :
• At abdomen : distended, tense, decreased bowel sound ,
tenderness (+), rebound tenderness (+), muscular rigidity (+),
liver dullness (-)
• DRE : weak sphincter tone, smooth mucosa, ampula wasn’t
collapsed, tenderness (+) at whole direction
 Gloves : stool (+), blood (-)
Laboratory finding
• PTT : 17,9 • BGA
• APTT : 41,9 pH : 7,450
• INR : 1,61 PCO2 : 26.0
• Hb : 11.3 g/dl PO2 : 59.0
• Ht : 34 % HCO3 : 18.0
• WBC : 17.700/mm3 TCO2 : 18.0
• Plt : 245.000/mm3 BE : -4.0
• Ureum : 56 mg/dl SaO2 : 91.0
• Creatinin : 0.64 mg/dl
• AST : 16 U/l Laktat : 4.2
• ALT : 11 U/l
• Sodium : 138 mEq/l Urinalysis : within normal
• Potasium : 3.6 mEq/l limit
• Glucose at random : 101 mg/dl
Abdominal x-ray
Free Air (+)
• WD/ :
Diffused peritonitis due to hollow viscus perforation
due to susp. peptic ulcer perforation (K65.0) + Severe
Sepsis

• Th/:
EGDT
Antibiotics
Exploratory laparotomy (54.11)
Observation
Time BP ( mmHg) PR(x/m) RR(x/m) T UO(cc/hr) Information

19.00 130/90 112 28 36,8 At abdomen : distended, tense,


decrease bowel sound , tenderness (+),
rebound tenderness (+), muscular
rigidity (+), liver dullness (-)
20.00 120/90 108 30 50/hr Hb : 11.3/Ht : 34/WBC: 17.700/Plt : 245.000
Ur: 56 /Cr: 0.64 /AST : 16 /ALT : 11
Na: 138 /K: 3.6
Glucose at random : 101 mg/dl
BGA : pH :7,450/PCO2:26.0/PO2:59.0/HCO3
:18.0
TCO2 : 18.0/BE : -4.0/SaO2:91.0
Lactat : 4.2
Consent for EGDT (-)
21.00 130/70 110 30 36,6 50/hr

22.00 120/80 106 28 40/hr


23.00 130/70 108 28 36,7 45/hr Performed EGDT
CVP: 6 cmH20
Consent (+)  plan to LE
24.00 120/70 112 30 40/hr CVP: 8 cmH2O
01.00 120/80 110 28 36.9 50/hr
Time BP ( mmHg) PR(x/m) RR(x/m) T UO(cc/hr Information
)

02.00 120/70 116 28 36,5 40cc/hr CVP: 12 CmH2O


03.00 130/80 112 28 45cc/hr

04.00 130/70 108 30 50cc/hr BGA


pH :7,340/PCO2:35.0/PO2:107.0/HCO3
:20.0
TCO2 : 21.0/BE : -3.0/SaO2:98.0
05.00 120/80 110 28 36,6 50 cc/hr Patient was sent to OR
IOF at 28/03/2012,
dr. Kristiani, dr. Ratin,dr. Arief SpB

We found :
• Pneumoperitoneum (+)
• Peritoneal fluid mixed with gastric juice 1000 cc
• Gastric perforation at prepyloric region, 1 cm in
diameter with necrotic border.
• Pocket abscess at subhepatic, both subphrenic, both
paracolica, pelvic and intestine interloop
• Fibrins at bowel interloop that still easily to be
removed
• Other solid and hollow viscera organs were normal
Post op diagnosis :
Diffused peritonitis due to gastric perforation (K65.0)
+ severe sepsis
Th/ :
Exploratory laparotomy (54.11) + biopsy + primary
suture + omental patch

INA-DRG : 061302 IP non-complex stomach, esofageal and duodenal procedures w/CC


ALOS : 23,7 days